BACKGROUND: The evolution toward minimally invasive surgery and subsequently to natural orifice translumenal endoscopic surgery (NOTES) poses challenges to the surgeon in terms of increased task complexity requiring greater visuospatial and navigational ability. Neuroergonomics is the study of the brain and behavior at work, and establishing the baseline cortical response for NOTES procedures will help to ascertain whether technological innovation such as navigational aids can alleviate the task-induced cognitive burden. The aims of the current study are to characterize the impact of navigation within a NOTES environment on the subject in terms of (1) performance, (2) stress, (3) prefrontal cortical activity, and (4) how this is influenced by expertise. METHODS: In all, 29 subjects were assessed for performance, stress response, and prefrontal cortical activity during a NOTES navigational task within a validated NOTES simulator. RESULTS: Experts performed significantly better than novices (P < .05). Expertise was not a predictor for overall changes in prefrontal cortical activity. The differences between experts and novices were modulated by the location of prefrontal cortical activity, with experts demonstrating more pronounced lateral prefrontal cortical activation compared with novices. Stress was not an independent predictor of changes in prefrontal cortical hemodynamics. CONCLUSION: This study is the first to characterize the performance, stress, and neurocognitive behavior associated with natural orifice translumenal endoscopic surgery navigation. The results indicate the relevance of visuospatial centers in successful task execution, and they serve as a baseline within the neuroergonomic paradigm for investigating performance-enhancing technology.

“Are bilateral axillary incisions needed or is just a single unilateral incision sufficient for robotic-assisted total thyroidectomy?”

Kandil, E., M. Abdel Khalek, et al. (2011).

Archives of Surgery 146(2): 240-241.

“Can single incision laparoscopic surgery be considered primarily for patients with complicated appendicitis?”

Kim, S. H. and J. M. Kwak (2010).

Journal of the Korean Society of Coloproctology 26(6): 373-374.

“Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: Summary of the working group reports of the Euro-NOTES meeting 2010.”

BACKGROUND: Using the da Vinci robot in low anterior resection (LAR) has not been widely adopted due to limited range of motion of the robotic arms and the need to move the robot during operations. Our technique uses all three arms for both the splenic flexure and the pelvis, but with only one docking position. METHODS: The robot is placed to the left of the patient. The camera port is 3 cm to the right of the umbilicus. Arm 1 is placed in the RLQ. Arm 2 is placed midepigastric. Arm 3 is placed in the LLQ. Arm 3 starts off on the left side of the robot, on the same side as Arm 1 aimed cephalad. During mobilization of colon and splenic flexure, Arms 2 and 3 help retract the colon while Arm 1 dissects. Our pelvic dissection begins with Arm 3 “flipped” to the right side of the robot and redocked to the same left sided port aimed caudally. The robot does not need to be repositioned and the patient does not need to be moved. The pelvic dissection can now be done in the standard fashion. RESULTS: Our early experience includes four patients: two LARs and two left hemicolectomies. Mean operative time = 347 minutes, docking time = 20 minutes, and robotic surgical time = 195 minutes. Two complications occurred: post-operative ileus and high ostomy output. Mean LOS = 5. CONCLUSIONS: The robotic “flip” arm technique allows the surgeon to fully utilize all the robotic arms in LAR, which is unique versus other techniques. Copyright (c) 2011 John Wiley & Sons, Ltd.

“Laparo-endoscopic single site (LESS) management of benign kidney diseases: Evaluation of complications.”

Permpongkosol, S., P. Ungbhakorn, et al. (2011).

Journal of the Medical Association of Thailand 94(1): 43-49.

Background: To present our experience with Laparo-Endoscopic Single Site (LESS) management of benign kidney diseases. Material and Method: Between September 2008 and November 2009, 18 patients underwent single port transumbilical laparoscopic surgery for nephrectomy for a nonfunctioning kidney (7 cases), cyst decortications for symptomatic renal cyst (10 cases), and redo-dismembered pyeloplasty with previously failed laparoscopic surgical repair (1 case). Patients underwent surgery through a single 2-cm infraumbilical incision with the triport laparoscopic-port. All pathological reports of LESS nephrectomy and cyst decortications confirmed with chronic pyelonephritis and simple cysts, respectively. Histology of xanthogranulomotus pyelonephritis showed two cases of the nephrectomy procedure. Results: Mean patient age and BMI were 61 ± SD 14.2 years and 24.75 ± SD 11.2 kg/m2, respectively. Mean operating time was 187.7 ± SD 71.4 min. LESS was a possible and safe approach in 77.8% of patients. All LESS cyst decortications and redo-pyeloplasty were completed without major complications or conversion to open surgery. However, there was one case each of LESS cyst decortication and pyeloplasty requiring an additional 3-mm port for suturing due to bleeding and an instrument error. For LESS nephrectomy, two (28.6%) with higher waist circumference were converted to standard laparoscopic nephrectomy due to failure to progress. One post operative complication of incisional hernia occurred in a patient with chronic bronchitis and asthma. Conclusion: LESS for the management of benign kidney diseases is an effective and safe treatment option with selected patients and experienced surgeon.

BACKGROUND: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. OBJECTIVE: To report our early experience with R-LESS radical nephrectomy (RN). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. SURGICAL PROCEDURE: R-LESS RN was performed using methods outlined in the manuscript and supplemental video material. All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. MEASUREMENTS: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2kg/m(2). There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p=0.049) and a shorter length of stay (2.5 d vs 3.0 d; p=0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. CONCLUSIONS: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery.

“Maximizing coupling strength of magnetically anchored surgical instruments: How thick can we go?”

An inherent characteristic of biological vessels and tissues is that they exhibit significant compliance or flexibility, both in the normal and tangential directions. The latter in particular is atypical of standard engineering materials and presents additional challenges for designing robotic mechanisms for navigation inside biological vessels by crawling on the tissue. Several studies aimed at designing and building wormlike robots have been carried out, but little was done on analyzing the interactions between the robots and their flexible environment. In this study, we will analyze the interaction between earthworm robots and biological tissues where contact mechanics is the dominant factor. Specifically, the efficiency of locomotion of earthworm robots is derived as a function of the tangential flexibility, friction coefficients, number of cells in the robot, and external forces.